Get Appointed – Ramsgate Insurance

GET STARTED

AGENCY/BROKERAGE INFORMATION

Business Name *

Business Phone *

Business Ext

Business Fax

Business Email *

Address Line 1 *

Address Line 2

City *

State Code *

Zip Code *

Is the mailing address the same as the physical address? *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Website URL

Year Established *

Primary Contact First Name *

Primary Contact Middle Name

Primary Contact Last Name *

Contact Email1 *

Work Email

Mobile Phone

Work Phone *

Business Entity Type *

% of Commercial Lines Business *

Are you appointed with The Hartford for Commercial Lines? *

Would you like the ability to quote directly with The Hartford? *

Are you appointed with Travelers for Commercial Lines? *

Do you have a current E&O Policy? *

Expiration Date

MM/DD/YYYY

Would you like an E&O quote at renewal? *

OWNERSHIP INFORMATION

Agency/Brokerage Ownership Name/s *

LICENSING INFORMATION

State/s Licensed In

Current E&O Policy *

Agency/ Brokerage License/s

Home State Agency/Brokerage License (Company). Attach additional states licensed in same file.

Agent/Broker License/s (P&C/Life/Health) *

Home State Agent/Broker License requesting appointment. Attach additional states licensed in same file.

Agent/Broker NPN (National Producer Number)

State Drivers License *

Agent/Broker requesting appointment.

CERTIFY INFORMATION

Certify *

Yes

I understand that the information provided herein is essential and material to the agency/broker relationship and herby certify the above answers are truthful and accurate, to the best of my knowledge.